HARVARD  HEALTH  TALKS 

THE  CARE  OF  CHILDREN 
BY  JOHN  LOVETT  MORSE 

PRESERVATIVES  AND  OTHER 
CHEMICALS  IN  FOODS:  THEIR  USE 

AND  ABUSE 
BY  OTTO  FOLIN 

THE  CARE  OF  THE  SKIN 

BY  CHARLES  JAMES  WHITE 

THE  CARE  OF  THE  SICK  ROOM 

BY  ELBRIDGE  GERRY  CUTLER 

THE  CARE  OF  THE  TEETH 
BY  CHARLES  ALBERT  BRACKETT 

ADENOIDS  AND  TONSILS 
BY  ALGERNON  COOLIDGE 

AN  ADEQUATE  DIET 
BY  PERCY  GOLDTHWAIT  STILES 

HOW  TO  AVOID  INFECTION 
BY  CHARLES  VALUE  CHAPIN 

PNEUMONIA 
BY  FREDERICK  TAYLOR  LORD 


HARVARD  HEALTH  TALKS 


HARVARD  HEALTH  TALKS 


PNEUMONIA 

BY 
FREDERICK  TAYLOR  LORD,  A.B.,  M.D. 

VISITING  PHYSICIAN,  MASSACHUSETTS  GENERAL  HOSPITAL 


CAMBRIDGE 

HARVARD  UNIVERSITY  PRESS 
1922 


COPYBIGHT,  1922 
HARVARD  UNIVERSITY  PRESS 


HARVARD  HEALTH  TALKS 

PRESENTING  the  substance  of  some 
-*  of  the  public  lectures  delivered  at 
the  Medical  School  of  Harvard  Univer- 
sity, this  series  aims  to  provide  in  easily 
accessible  form  modern  and  authorita- 
tive information  on  medical  subjects 
of  general  importance.  The  following 
committee,  composed  of  members  of 
the  Faculty  of  Medicine,  has  editorial 
supervision  of  the  volumes  published : 

EDWARD  HICKLING  BRADFORD, 
A.M.,  M.D.,  Dean  of  the  Faculty  of 
Medicine,  and  Professor  of  Orthopedic 
Surgery,  Emeritus. 

HAROLD  CLARENCE  ERNST,  A.M., 
M.D.,  Professor  of  Bacteriology. 

WALTER  BRADFORD  CANNON,  A.M., 
M.D.,  George  Higginson  Professor  of 
Physiology. 


PNEUMONIA 


PNEUMONIA 

REFERRING  to  pneumonia,  Osier 
writes:  "One  of  the  most  wide- 
spread and  fatal  of  all  acute  diseases, 
pneumonia  has  become  the  'Captain  of 
the  men  of  Death'  to  use  the  phrase 
applied  by  John  Bunyan  to  consump- 
tion." 

FREQUENCY  AND  IMPORTANCE 

In  this  country  about  10  per  cent  of  all 
deaths  are  each  year  due  to  some  form  of 
pneumonia  and  this  annual  toll  of  lives 
has  been  maintained  with  little  apparent 
variation  for  many  years.  Strictly  com- 
parable statistics  are  lacking  for  other 
communities  but,  making  due  allowance 
for  differences  in  classification,  a  similar 
high  prevalence  seems  to  obtain  also  in 
other  civilized  countries  in  which  mor- 
tality statistics  are  available. 


HARVARD  HEALTH  TALKS 

While  the  disease  is  constantly  a 
menace  and  thus  termed  endemic,  nu- 
merous instances  might  be  cited  of  more 
or  less  severe  local  outbreaks  or  epi- 
demics at  certain  times  and  in  certain 
places  as  a  succession  of  cases  in  the 
same  house,  on  shipboard,  in  hospitals 
and  in  jails.  Conditions  of  overcrowding 
are  largely  responsible  for  such  epi- 
demics. In  1906  the  death  rate  among 
negroes  employed  in  the  construction  of 
the  Panama  Canal  reached  eighteen  per 
thousand.  A  similar  high  mortality  has 
been  noted  among  negroes  employed  in 
the  mines  on  the  Rand  and  in  1912  the 
death  rate  from  pneumonia  was  twenty- 
six  per  thousand.  In  Panama  and  on  the 
Rand  the  highest  mortality  occurred 
among  the  recent  arrivals  and  the  mor- 
tality rapidly  diminished  after  a  short 
residence  in  the  community. 

We  have  unfortunately  just  passed 
through  a  period  of  greatly  increased 
prevalence  of  pneumonia  during  and 
10 


PNEUMONIA 

after  the  influenza  pandemic.  In  the 
absence  of  any  reliable  figures  it  is  futile 
to  speculate  as  to  the  number  of  deaths 
from  pneumonia  in  the  country  at  large 
during  the  scourge  of  influenza,  but  the 
importance  of  pneumonia  as  a  cause  of 
death  is  strikingly  illustrated  in  the  re- 
port of  Vaughan  and  Palmer  for  the 
United  States  Army  during  the  World 
War.  Of  about  4,000,000  men,  about 
40,000  perished  in  combat  and  47,000 
died  from  disease.  Pneumonia  accounted 
for  more  than  50  per  cent  of  the  deaths 
from  disease  prior  to  the  influenza  pan- 
demic in  1918  and  for  93.7  per  cent  dur- 
ing the  period  covered  by  the  pandemic. 
Men  from  the  rural  districts  and  the 
southern  communities  suffered  most 
severely.  Excluding  the  influenza  period 
from  consideration,  pneumonia  was  nine 
times  more  frequent  among  the  men  in 
the  army  than  among  civilians  of  the 
same  age  group.  The  high  incidence 
of  pneumonia  in  the  army  may  be 
11 


HARVARD  HEALTH  TALKS 

ascribed  to  epidemics  of  measles  and 
influenza  followed  by  pneumonia,  an 
increased  opportunity  for  contagion  in 
the  close  proximity  of  susceptible  indi- 
viduals in  barracks,  tents,  and  the  mess, 
and  a  lowering  of  resistance  from  ex- 
posure, overwork,  and  fatigue. 

TYPES  OF  PNEUMONIA 

I  have  thus  far  spoken  of  pneumonia 
without  distinction  as  to  type  and  be- 
fore proceeding  further  it  will  be  neces- 
sary to  define  the  two  recognized  forms 
of  the  disease;  one  is  spoken  of  as 
lobar  pneumonia  from  the  more  or  less 
complete  involvement  of  one  or  more 
lobes  of  the  lung  in  an  inflammatory 
process.  In  this  type  there  is  practically 
always  one  group  of  bacteria,  called 
pneumococci,  to  be  found  in  the  lung 
and  frequently  also  in  the  blood.  Lobar 
pneumonia  is  a  disease  with  a  well-de- 
fined and  uniform  onset,  usually  with 
initial  chill,  rapid  elevation  of  tempera- 

12 


PNEUMONIA 

ture,  pain  in  the  side,  cough  and  bloody 
expectoration,  running  a  febrile  course 
of  about  seven  days  and  terminating 
abruptly  in  favorable  cases.  The  second 
type  is  known  as  bronchopneumonia 
and  here  the  bronchi  or  smaller  air  pas- 
sages and  even  their  smallest  ramifica- 
tions in  the  lungs  together  with  the  ad- 
jacent or  terminal  air  vesicles  and  the 
neighboring  lung  are  the  site  of  an  in- 
flammation. In  bronchopneumonia  the 
infecting  agents  are  usually  micro-or- 
ganisms normally  inhabiting  the  mouth, 
and  hence  the  bacterial  flora  of  the 
mouths  of  normal  persons  to  a  consider- 
able degree  determines  the  bacteriology 
of  the  disease.  The  pneumococcus  is  the 
most  common  single  cause  but  other  or- 
ganisms are  also  concerned  and  mixed 
infections  with  more  than  one  kind  of 
bacteria  are  not  uncommon.  In  con- 
trast to  the  usual,  well-defined  and  uni- 
form onset  and  abrupt  termination  of 
the  symptoms  in  lobar  pneumonia,  bron- 

13 


HARVARD  HEALTH  TALKS 

chopneumonia  presents  a  variable  pic- 
ture, occurring  as  a  complication  of  con- 
ditions likely  to  mask  or  modify  its 
manifestations  and  with  a  variable  ex- 
tent of  lung  involvement. 

CAUSES 

In  considering  the  causes  of  pneumonia, 
it  is  desirable  to  distinguish  between 
the  predisposing  and  immediate  causes. 
Among  the  predisposing  causes  suscepti- 
bility is  increased  as  age  advances.  It  is 
greater  among  males  than  females,  prob- 
ably on  account  of  the  greater  oppor- 
tunity for  infection  in  occupations 
among  males.  The  subjects  of  chronic 
alcoholism  are  somewhat  more  prone  to 
have  pneumonia  as  suggested  by  an 
apparent  higher  percentage  of  heavy 
drinkers  in  patients  admitted  to  hospi- 
tals with  pneumonia  than  in  the  other 
patients  and  in  the  population  at  large. 
There  is  a  marked  seasonal  variation 
in  the  incidence  of  pneumonia,  a  large 

14 


PNEUMONIA 

majority  of  the  cases  occurring  during 
the  months  between  November  and 
June.  The  explanation  is  uncertain  but 
the  tendency  to  live  under  less  satisfac- 
tory hygienic  conditions  in  crowded  and 
poorly  ventilated  rooms  during  cold  and 
inclement  weather  may  be  responsible. 
A  greater  incidence  of  pneumonia  in  the 
city  than  in  the  country  suggests  that 
overcrowding  is  a  factor  of  importance. 
Close  contact  within  doors  increases  the 
opportunity  for  transmission  of  infected 
material  from  one  person  to  another 
through  the  distribution  of  particles  by 
loud  talking,  coughing,  and  sneezing  in 
houses,  theatres,  halls,  barracks,  street 
cars,  etc.,  and  contamination  by  fingers 
soiled  with  saliva  or  sputum.  ^ 

The  increased  susceptibility  of  recent 
arrivals  in  a  community,  as  in  the  United 
States  Army,  in  Panama,  and  on  the 
Rand,  may  be  ascribed  to  less  previous 
exposure  and  consequently  less  acquired 
resistance  to  organisms  which  abound  in 

15 


HARVARD  HEALTH  TALKS 

crowded  communities.  Such  debilitating 
conditions  as  hunger,  fatigue,  exposure 
to  wet  and  cold,  the  later  stages  of  car- 
diac disease  with  passive  congestion  of 
the  lung,  malignant  disease,  chronic 
nephritis,  cerebral  hemorrhage  and  other 
diseases  are  also  to  be  regarded  as  pre- 
disposing factors. 

A  history  of  acute  infection  such  as 
accompanies  an  ordinary  "cold"  can  be 
obtained  in  from  25  to  50  per  cent  of  all 
cases  of  lobar  pneumonia  and  such  in- 
fections may  be  regarded  as  important 
predisposing  factors,  the  specific  agent 
of  the  "cold"  (as  yet  unknown)  prob- 
ably acting  to  carry  down  the  cause  of 
pneumonia  into  the  deeper  parts  of  the 
respiratory  tract  and  leading  to  its  im- 
plantation in  the  lung.  Measles,  influ- 
enza, and  whooping  cough  are  also  not 
infrequently  followed  by  pneumonia, 
more  often  of  the  bronchopneumonic 
type.  In  these  three  diseases  the  specific 
cause,  likewise  unknown,  probably  acts 

16 


PNEUMONIA 

in  similar  fashion  to  implant  the  pneu- 
mococcus  within  the  deeper  parts  of  the 
tract. 

Bacterial  cause  of  pneumonia.  The 
pneumococcus  is  practically  the  only 
immediate  cause  of  lobar  pneumonia  and 
the  most  common  single  cause  of  bron- 
chopneumonia.  Our  knowledge  of  the 
organism  extends  over  a  period  of  thirty 
years  and  goes  back  to  its  independent 
and  almost  simultaneous  discovery  by 
Sternberg  in  September  and  by  Pasteur 
in  December,  1880.  Unfortunately  for 
American  medicine,  Sternberg's  article 
did  not  appear  until  April,  while  Pas- 
teur's publication  is  dated  January,  1881, 
and  the  priority  of  the  discovery  there- 
fore belongs  to  Pasteur.  The  importance 
of  the  pneumococcus,  however,  was  not 
appreciated  until  its  frequent  presence  in 
pneumonia  was  established  by  Fraenkel 
in  1884  and  later  by  Weichselbaum  in 
1886.  It  is  a  lance-shaped  organism 
occurring  in  pairs  or  chains. 

17 


HARVARD  HEALTH  TALKS 

The  pneumococcus  has  interesting 
biologic  peculiarities  which  are  doubtless 
concerned  in  its  behavior  as  an  infecting 
agent.  It  is  very  sensitive  to  change  in 
the  reaction  of  the  media  in  which  it 
grows  and  growth  can  be  started  in  arti- 
ficial media  only  at  a  reaction  very  close 
to  that  of  the  circulating  blood  which  is 
slightly  alkaline.  In  artificial  media  con- 
taining carbohydrate  such  as  glucose, 
however,  growth,  once  started  at  a 
slightly  alkaline  reaction,  proceeds  until 
the  media  become  slightly  acid,  further 
multiplication  being  inhibited  by  the 
acid  produced.  Its  extreme  sensitiveness 
to  acid  may  be  better  appreciated  when 
it  is  stated  that  the  range  between 
the  slightly  alkaline  reaction  of  normal 
blood  and  that  of  the  culture  containing 
glucose  in  which  death  of  the  organism 
takes  place  is  about  that  between  ordi- 
nary tap  water  and  distilled  water  stand- 
ing in  the  laboratory. 

The  lower  animals  vary  in  their  sus- 

18 


PNEUMONIA 

ceptibility  to  infection  with  the  pneu- 
mococcus,  chickens  and  pigeons  being 
immune,  and  rabbits,  rats,  and  mice 
highly  susceptible.  The  readiness  with 
which  artificial  infection  of  these  lower 
animals  can  be  produced  in  the  labora- 
tory has  led  to  an  important  addition  to 
our  knowledge  of  the  organism  and  an 
advance  in  treatment  of  one  type  of  the 
disease  with  consequent  reduction  of 
mortality. 

The  pneumococcus  is  found  in  the 
saliva  of  more  than  one  half  of  all  normal 
persons.  It  is  only  within  the  past  ten 
years,  however,  that  we  have  known 
that  all  types  of  pneumococci  are  not  of 
equal  importance  and  it  will  be  a  reassur- 
ance for  me  to  state  at  once  that  the 
kind  most  frequently  the  cause  of  the 
more  severe  types  of  pneumonia  is  not 
commonly  present  in  the  normal  mouth. 


19 


HARVARD  HEALTH  TALKS 

TYPES  OF  PNEUMOCOCCI 

Previous  to  the  work  of  Neufeld  (Arb. 
a.  d.  Kais.  Gesund.  1910,  xxxiv,  293)  in 
Germany  and  of  Dochez  and  Gillespie 
(Journal  Am.  Med.  Ass.,  Sept.  6,  1913, 
Ixi,  727),  in  this  country,  it  was  thought 
that  there  was  no  essential  difference  in 
the  strains  of  pneumococci.  By  the  re- 
peated inoculation  of  horses  with  differ- 
ent strains  it  has  been  found,  however, 
that  after  a  time  the  animal's  resistance 
against  the  organisms  injected  is  such 
that  when  its  blood  is  taken  and  allowed 
to  separate  into  serum  and  clot,  the 
serum  will  protect  white  mice  against  an 
otherwise  fatal  dose  of  certain  strains  of 
pneumococci.  The  serum  is  not  only  pro- 
tective but  will  also  cure  an  otherwise 
fatal  infection.  It  is  further  found  that 
these  strains  against  which  the  horse 
serum  is  effective  can  be  recognized  by  a 
clumping  or  agglutination  of  the  pneu- 
mococci when  mixed  in  suspension  with 
20 


PNEUMONIA 

the  horse  serum.  By  such  protective  and 
clumping  experiments  three  so-called 
"fixed"  types  of  organisms  have  been 
separated  out  of  the  great  group  of  pneu- 
mococci.  In  the  first  column  (A)  of  the 
table  (page  23)  the  groups  are  indicated 
by  the  Roman  numerals.  The  types 
numbered  I,  II,  and  III  are  the  fixed 
types.  Type  IV  is  made  up  of  pneumo- 
cocci  with  apparent  individual  characters 
and  resistance  against  one  strain  of  this 
type  confers  no  protection  against  other 
strains.  It  is  thus  spoken  of  as  a  hetero- 
geneous group.  As  shown  in  the  second 
column  (B)  Types  I  and  II  are  only 
rarely  present  in  the  normal  mouth,  while 
Types  III  and  IV  are  common.  Among 
persons  intimately  associated  with  pa- 
tients with  lobar  pneumonia,  however, 
such  as  attendants,  relatives  or  friends, 
the  percentage  of  those  who  harbor  Type 
I  or  II  pneumococci  may  rise  as  high  as 
13.0  per  cent.  (A very,  Chickering,  Cole, 
and  Dochez.  Monographs  of  the  Rocke- 


HARVARD  HEALTH  TALKS 

feller  Institute  for  Medical  Research, 
No.  7,  October  16,  1917,  p.  95.) 

Relation  of  types  of  pneumococci  to 
types  of  pneumonia.  I  cannot  give  you 
statistics  on  the  incidence  of  the  different 
types  in  bronchopneumonia  but  their 
approximate  frequency  is  indicated  by 
the  plus  signs  in  the  column  (C).  As  in 
the  saliva  of  normal  persons  Type  IV  is 
most  common,  Type  III  is  probably 
next  in  frequency  and  Types  II  and  I  are 
rarely  present.  I  would  like  to  point  out 
also  that  the  similar  grouping  in  the 
saliva  of  normal  persons  and  in  broncho- 
pneumonia  is  what  we  should  expect  as 
the  infection  here  is  usually  due  to  bac- 
teria commonly  inhabiting  the  mouth 
and  carried  down  into  the  deeper  parts 
of  the  respiratory  tract. 

The  approximate  distribution  of  types 
in  lobar  pneumonia,  determined  by  Cole 
and  his  associates,  is  shown  in  the  fourth 
column  (D).  Out  of  every  100  cases 
about  thirty  are  due  to  infection  with 

22 


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HARVARD  HEALTH  TALKS 

Type  I,  about  thirty  to  Type  II,  fifteen 
to  Type  III  and  twenty-five  to  Type  IV. 
The  low  incidence  of  Type  I  and  II  in 
the  normal  mouth  and  their  high  inci- 
dence, 60  per  cent  as  a  cause  of  lobar 
pneumonia,  is  in  accord  with  the  be- 
havior of  other  disease-producing  bac- 
teria, such  for  example  as  the  Diphtheria 
bacillus  which  may  be  harbored  by  a 
small  proportion  of  normal  persons  with- 
out giving  rise  to  the  disease  diphtheria. 
The  limitation  of  Type  I  and  II  to  pa- 
tients with  lobar  pneumonia  and  to 
those  in  contact  with  such  patients  sug- 
gests that  pneumonia  due  to  these  two 
types  of  pneumococci  is  largely  acquired 
by  contact  with  patients  with  or  recently 
recovered  from  pneumonia,  or  by  con- 
tact with  a  healthy  carrier  who  has  been 
exposed  to  a  patient  with  pneumonia. 
Pneumonia  due  to  Type  I  and  II  pneu- 
mococci is  thus  to  be  regarded  as  a 
communicable  disease  and  such  a  con- 
sideration makes  it  desirable  to  isolate 

24 


PNEUMONIA 

patients  with  lobar  pneumonia  and  thus 
protect  other  persons  so  far  as  possible. 
Type  III  and  Type  IV  lobar  pneu- 
monias, which  together  represent  about 
40  per  cent  of  the  cases,  may  be  regarded 
as  due  to  auto-infection  from  organisms 
normally  inhabiting  the  mouth,  but  in- 
creased virulence  of  these  pneumococci 
or  diminished  resistance  of  the  host  may 
also  be  of  importance  in  giving  rise  to 
pneumonia. 

"CRISIS"  IN  PNEUMONIA 

I  have  already  referred  to  the  abrupt 
termination  of  lobar  pneumonia  in  favor- 
able cases.  This  turn  of  events  in  the 
disease  is  spoken  of  as  "crisis"  and  some 
apprehension  is  naturally  felt  by  anxious 
relatives  when  this  term  is  used,  but 
when  crisis  occurs  in  pneumonia  it  is 
usually  a  favorable  event,  during  which 
the  temperature  falls  to  normal  with- 
out any  accompanying  emergency  and 
within  twelve  to  twenty-four  hours  there 

26 


HARVARD  HEALTH  TALKS 

is  a  rapid  transition  from  a  condition  of 
great  gravity  to  one  of  safety.  The  crisis 
is  usually  an  indication  of  a  decisive 
victory  won  by  the  patient  against  the 
disease. 

Factors  Underlying  Crisis  and  Recov- 
ery. The  determination  of  the  factors 
underlying  crisis  and  recovery  from 
lobar  pneumonia  is  one  of  the  most  in- 
teresting fields  for  research.  Much  valu- 
able knowledge  has  already  been  won 
but  there  is  still  much  to  be  learned.  A 
complete  explanation  may  be  expected 
to  open  the  way  to  still  further  advance 
in  treatment.  Our  present  conception  is 
that  recovery  is  a  dual  mechanism,  on 
the  one  hand  dependent  on  the  develop- 
ment of  a  general  resistance  against  the 
pneumococcus  during  the  course  of  the 
disease  and  on  the  other  certain  chemical 
changes  in  the  involved  lung  itself  lead- 
ing to  death  of  the  organism. 

There  is  considerable  evidence  in 
favor  of  the  development  of  a  general  re- 

26 


PNEUMONIA 

sistance  (humoral  immunity)  during  the 
short  period  from  the  onset  to  the  ter- 
mination of  the  pneumonia.  The  evi- 
dence is  at  first  sight  somewhat  conflict- 
ing and  apparently  paradoxical  because 
of  the  frequency  with  which  recurrent 
attacks  of  pneumonia  may  occur  in  the 
same  individual.  This  may  be  due,  how- 
ever, to  the  fact  that  the  resistance 
acquired  by  one  attack  is  sufficient  to 
terminate  that  attack  without  affecting 
any  lasting  protection.  The  more  recent 
additions  to  our  knowledge  of  the  differ- 
ent types  of  pneumococci  suggest  an- 
other and  more  plausible  explanation.  I 
have  already  referred  to  the  increase  of 
resistance  in  horses  following  repeated 
injections  of  different  strains  as  a  means 
of  recognizing  the  fixed  types  of  pneu- 
mococci. By  such  injections  rabbits  as 
well  as  horses  can  be  rendered  highly 
immune  against  many  times  the  other- 
wise fatal  dose  of  pneumococci  of  Type 
I,  II,  or  III.  The  resistance  thus  artifi- 

27 


HARVARD  HEALTH  TALKS 

cially  induced,  however,  is  protective 
only  against  the  same  type  of  pneumo- 
cocci  as  that  used  in  the  injection  and 
not  against  any  other  type.  While  occa- 
sional instances  of  Type  I,  II,  or  III 
pneumonia  in  man  are  known  to  have 
been  followed  by  a  second  attack  due  to 
the  same  type  as  that  concerned  in  the 
first  infection,  the  repetition  is  usually 
due  to  pneumococci  of  another  type, 
suggesting  that  in  man  an  immunity 
may  be  induced  against  one  but  not 
against  another  type.  Other  evidence  is 
also  confirmatory  in  man  of  the  building 
up  of  resistance  against  the  particular 
type  giving  rise  to  the  pneumonia. 
Blood  from  patients  with  Type  I,  II,  or 
III  pneumonia  obtained  at  about  the 
time  of  crisis  and  injected  into  animals 
has  the  power  of  protecting  them  against 
an  otherwise  fatal  dose  of  the  same  type 
of  pneumococci.  It  is  ineffective  in  pro- 
tective power  against  any  other  than  the 
same  type,  indicating  a  specific  response 

28 


PNEUMONIA 

in  the  individual  against  the  particular 
type  giving  rise  to  the  infection  but  not 
against  any  other  type. 

Local  chemical  factors  may  also  be 
regarded  as  of  influence  in  recovery. 
Mention  has  already  been  made  of  the 
susceptibility  of  the  pneumococcus  to 
changes  of  reaction  in  the  media  in  which 
it  grows  and  of  its  rapid  death  in  the 
presence  of  a  slight  degree  of  acidity.  As 
the  inflammatory  process  in  the  lung 
goes  through  its  evolution  two  signifi- 
cant changes  take  place  in  the  involved 
region.  The  amount  of  blood  diminishes 
and  the  reaction,  so  far  as  we  can  learn 
from  animal  experiment  and  tests  of  the 
lung  immediately  after  death,  changes 
from  slightly  alkaline  to  a  degree  of 
acidity  which  is  within  the  range  of  the 
acid  death  point  of  the  pneumococcus. 
In  the  study  of  these  factors  we  have 
recently  found  that  there  is  an  impor- 
tant relation  between  the  amount  of 
blood  serum  and  the  effect  of  acidity  on 

29 


HARVARD  HEALTH  TALKS 

the  pneumococcus,  serum  protecting  the 
organism  to  a  certain  extent  from  de- 
grees of  acidity  which  would  otherwise 
kill  it.  At  an  acidity  corresponding  to 
that  which  the  inflammatory  process 
may  reach,  however,  the  duration  of  life 
of  the  pneumococcus  in  fluid  culture 
media  without  serum  is  only  about  two 
hours  and  even  100  per  cent  serum  may 
not  suffice  to  prolong  the  life  of  the  cul- 
ture for  more  than  twenty-four  hoiirs. 
In  explanation  of  recovery  from  a  chemi- 
cal point  of  view  it  may  be  conceived 
that  as  the  evolution  of  the  local  process 
takes  place  with  an  increase  of  acidity 
and  diminishing  amount  of  serum  the 
acid  death  point  of  the  pneumococcus  is 
reached  and  crisis  and  recovery  follow. 

RESOLUTION 

Another  interesting  aspect  of  lobar  pneu- 
monia  is    a   most   remarkable    change 
which  takes  place  in  the  inflammatory 
so 


PNEUMONIA 

process  in  the  lung.  In  consequence  of 
the  infection  with  the  pneumococcus  the 
affected  region  becomes  firm  and  solid 
from  the  presence  everywhere  within  the 
smallest  air  spaces  of  great  numbers  of 
cells  technically  known  as  polymorpho- 
nuclear  leucocytes  or  pus  cells  and  a 
fine  network  of  delicate  threads  which 
permeate  the  whole  structure.  These 
threads  are  threads  of  fibrin  and  you  are 
all  familiar  with  an  important  result  of 
their  presence  in  shed  blood  which  they 
cause  to  coagulate  or  clot  shortly  after 
its  escape  from  the  blood  vessel.  At  the 
same  time  or  shortly  after  the  crisis  this 
solid  lung  begins  to  soften,  sooner  or 
later  air  again  enters  the  region  and 
finally  in  spite  of  the  profound  inflam- 
matory changes  through  which  it  has 
passed  it  is  restored  exactly  to  the  func- 
tional capacity  existing  before  the  pneu- 
monia, no  trace  of  which  now  remains. 
This  extraordinary  transformation  is 
spoken  of  as  resolution. 

31 


HARVARD  HEALTH  TALKS 

Factors  Underlying  Resolution.  That 
resolution  can  occur  without  permanent 
damage  to  the  lung  itself  is  due  to  the 
fact  that  the  products  of  the  inflamma- 
tory process  are  poured  out  into  the  air 
spaces  with  little  involvement  of  the 
framework  of  the  lung  itself  in  which  the 
circulation  of  blood,  though  impaired,  is 
still  maintained.  The  softening  of  the 
exudate  without  damage  to  the  lung 
tissue  is  accomplished  by  three  interest 
ing  and  delicately  balanced  factors. 

The  principal  agent  in  the  transfor- 
mation is  a  peculiar  substance  liberated 
by  the  pus  cells  which  have  migrated  to 
the  air  spaces  and  form  part  of  the  in- 
flammatory process.  This  remarkable 
substance  is  known  as  an  enzyme  (or 
ferment).  If  you  are  not  already  famil- 
iar with  the  fundamental  importance  of 
enzymatic  action  in  and  outside  the 
body,  I  may  emphasize  it  by  saying  that 
to  enzymatic  action  is  to  be  ascribed  the 
ripening  of  fruit,  the  tenderness  and  taste 

32  \ 


PNEUMONIA 

of  meat,  the  alcoholic  fermentation  of 
sugar  by  the  yeast  cell,  the  digestion  of 
food  in  the  stomach  and  intestines  and 
in  fact  the  chemical  activity  of  all  living 
plant  or  animal  cells.  Ferment  action  in 
the  body  is  a  powerful  force  for  good  but 
must  be  prevented  from  doing  harm  by 
some  regulatory  mechanism.  Two  pro- 
tective factors  hold  it  in  check  in  the 
body.  Enzymatic  action  is  inhibited  by 
the  blood  serum  and  does  not  take  place 
when  there  is  an  abundance  of  blood. 
The  action  of  enzymes  is  largely  depend- 
ent also  upon  the  reaction  of  the  medium 
in  which  the  enzyme  occurs.  Thus  the 
enzyme  of  the  gastric  juice  works  best  in 
a  strongly  acid  medium.  Two  enzymes 
are  demonstrable  in  the  pneumonic  lung, 
one  active  in  slightly  alkaline,  neutral, 
and  slightly  acid  media  and  another 
with  optimum  activity  in  still  more  acid 
media.  As  the  evolution  of  the  pneu- 
monic .process  takes  place  there  is  an 
increase  in  cells  containing  ferment,  a 

33 


HARVARD  HEALTH  TALKS 

diminution  of  serum  containing  antifer- 
ment,  and  a  shift  to  an  acid  reaction.  In 
the  balance  between  cellular  material 
and  serum,  enzymatic  action  is  absent 
with  more  and  present  with  less  than 
about  three  parts  serum  to  one  part 
cells.  Increase  of  cells  (enzyme),  diminu- 
tion of  serum  (antienzyme),  and  a  shift 
to  an  acid  reaction  thus  permit  of  the 
melting  away  of  the  exudate  and  restora- 
tion to  normal. 

DIAGNOSIS  OF  PNEUMONIA 

In  typical  cases  the  diagnosis  of  lobar 
pneumonia  is  readily  made  from  the 
history  of  an  acute  onset  with  chill, 
rapid  rise  of  temperature,  pain  in  the 
side,  cough  with  bloody  expectoration 
and  shortness  of  breath,  and  on  exami- 
nation the  signs  of  consolidation  in  the 
lung.  The  usual  occurrence  of  broncho- 
pneumonia  as  a  complication  of  some 
infection  of  the  upper  respiratory  tract, 
the  insidious  onset,  irregular  course  and 

34 


PNEUMONIA 

frequent  absence  of  definite  physical 
signs  make  the  diagnosis  of  broncho- 
pneumonia  difficult  and  at  times  impos- 
sible. In  fact,  it  often  happens  that  the 
diagnosis  of  bronchopneumonia  can  only 
be  regarded  for  a  time  as  probable  from 
the  attendant  circumstances,  the  symp- 
toms, and  the  physical  signs.  Into  the 
more  technical  aspects  of  the  diagnosis 

Kit  is  not  necessary  for  me  to  go. 
DIAGNOSIS  OF  THE  TYPE  OP 
PNEUMOCOCCI 

The  advances  in  treatment  of  one  type 
of  pneumonia  by  serum  make  it  impor- 
tant that  the  diagnosis  should  not  rest 
with  the  establishment  of  a  pneumonia. 
It  should  be  extended  to  determine  the 
presence  and  the  type  of  pneumococci 
concerned. 

Favorable  results  of  serum  treatment 
depend  on  the  earliest  possible  determi- 
nation of  Type  I  pneumococcus  and  it  is 
essential  that  a  specimen  of  sputum  be 

35 


HARVARD  HEALTH  TALKS 

obtained  and  sent  to  the  laboratory  as 
soon  as  possible.  The  sputum  should  be 
from  the  deeper  parts  of  the  air  pas- 
sages. It  should  be  collected  in  a  small, 
wide-mouthed,  clean  and  preferably 
sterile  bottle.  As  the  determination  of 
type  usually  depends  on  the  presence  of 
living  organisms  in  the  sputum  no  anti- 
septic should  be  added  to  the  specimen. 
In  the  laboratory  a  part  of  the  specimen 
is  examined  under  the  microscope  and  a 
small  amount  injected  into  the  abdomi- 
nal cavity  of  a  mouse.  Virulent  pneu- 
mococci  multiply  rapidly  in  the  mouse 
and  on  removal  of  the  abdominal  fluid 
their  type  can  be  determined  by  mixing 
pneumococci  thus  obtained  or  small 
amounts  of  the  abdominal  fluid  with 
sera  obtained  from  horses  each  immun- 
ized with  Type  I,  II,  or  III  pneumo- 
coccus.  A  correspondence  of  the  organ- 
ism giving  rise  to  the  pneumonia  to  one 
of  these  types  is  indicated  by  a  clumping 
or  precipitation  when  mixed  with  the 

86 


PNEUMONIA 

corresponding  serum.  A  diagnosis  of 
type  can  thus  be  made  usually  within 
eight  to  twenty-four  hours.  If  large 
amounts,  two  to  three  teaspoonfuls,  of 
sputum  can  be  obtained  a  rapid  precipi- 
tation method  may  permit  of  a  determi- 
nation of  type  within  a  few  minutes.  The 
State  Board  of  Health  of  Massachusetts 
determines  the  type  without  charge. 

PROGNOSIS 

The  outlook  for  life  in  lobar  pneumonia 
depends  upon  many  factors,  all  of  which 
cannot  be  considered.  In  general  it  may 
be  said,  as  shown  in  the  table,  Column 
E,  that  the  total  mortality  is  about  30 
per  cent.  These  figures  represent  the 
mortality  in  good  general  hospitals 
where  the  poorer  classes  are  admitted. 
Diminished  resistance  from  poor  nutri- 
tion, overwork,  fatigue,  and  chronic 
alcoholism  makes  the  death  rate  some- 
what higher  in  hospitals  than  may  be 

37 


HARVARD  HEALTH  TALKS 

expected  in  private  practice  where  the 
mortality  may  be  20  per  cent  or  even 
less.  Of  the  various  factors  influencing 
the  outcome  age  is  of  much  importance. 
Youth  is  favorable.  From  the  sixth  to 
the  twentieth  year  the  mortality  is  not 
far  from  6  per  cent.  It  rises  steadily  as 
age  advances  reaching  about  26  per  cent 
from  thirty-one  to  forty,  nearly  40  per 
cent  from  forty-one  to  fifty  and  may  rise 
as  high  as  65  per  cent  above  sixty  years 
of  age.  The  mortality  varies  also  ac- 
cording to  the  type  of  pneumococci  giv- 
ing rise  to  the  infection.  As  shown  in 
this  same  column  about  one  third  of  the 
cases  due  to  Type  I  and  Type  II  are  fatal. 
Nearly  one  half  the  patients  succumb 
to  Type  III  pneumonia  and  only  about 
one  eighth  to  Type  IV.  The  influence  of 
treatment  with  Type  I  serum  in  lowering 
the  mortality  of  Type  I  pneumococcus 
pneumonia  will  be  considered  later. 


PNEUMONIA 

PREVENTION 

I  want  next  to  call  your  attention  to 
certain  aspects  of  prevention  of  pneu- 
monia. This  is  a  difficult  matter  and  our 
limitations  must  be  at  once  acknowl- 
edged. The  high  incidence  of  pneu- 
monia in  our  army  camps  and  the 
scourge  of  post-influenza  pneumonia 
which  swept  the  country  in  the  fall  of 
1918  indicate  that  we  have  much  to 
learn  regarding  prevention.  Indeed  it 
would  almost  seem  from  the  undimin- 
ished  death  rate  from  pneumonia  over 
long  periods  of  years  that  our  efforts  are 
thus  far  wholly  unavailing. 

There  are  three  principal  means  of 
attack  upon  the  prevalence  of  the  dis- 
ease, one  already  available,  the  others 
promising  for  the  future. 

The  method  already  available  is  the 
application  to  pneumonia  of  such  knowl- 
edge as  we  already  possess  regarding  the 
transfer  of  infectious  material  from  per- 

39 


HARVARD  HEALTH  TALKS 

son  to  person  in  communicable  disease 
and  there  is  this  hopeful  aspect  for  the 
future,  that  such  transfer  has  not  been 
adequately  avoided  in  the  past.    The 
more  recent  knowledge  acquired  regard- 
ing the  distribution  of  types  of  pneumo- 
cocci  in  health  and  disease  suggests  that 
pneumonia  due  to  Type  I  and  Type  II 
pneumococci  arises  from  direct  contact 
with  patients  with  pneumonia  or  from 
contact  with  healthy  carriers  who  har- 
bor   these    organisms    in    consequence 
of    exposure  to  lobar  pneumonia.     As 
Type  III  and  Type  IV  pneumococcus 
commonly  inhabit  the  mouths  of   nor- 
mal persons,  however,  the  indication  is 
less  clear  regarding  the  prevention  of 
pneumonia    due   to    these    types.     We 
know,  however,  that  passage  of  bacteria 
through    susceptible   animals   increases 
their  virulence  and  transfer  of  pneumo- 
cocci of  whatever  type  from  patients 
with  pneumonia  to  those  about  them 
doubtless    favors    the    development    of 

40 


PNEUMONIA 

pneumonia.  These  considerations  should 
be  an  incentive  to  greatly  increased  cau- 
tion against  the  transfer  of  disease-pro- 
ducing pneumococci  from  person  to  per- 
son. Transfer  may  take  place  by  the 
contact  with  moist  sputum  or  utensils 
used  by  infected  individuals.  It  may  also 
occur  by  what  is  known  as  droplet  infec- 
tion through  the  inhalation  of  particles 
of  moist  sputum  expelled  by  talking, 
coughing,  or  sneezing,  or  by  the  inhala- 
tion of  material  which  through  drying 
may  contaminate  the  air.  Medical  clean- 
liness, in  the  sense  of  freedom  from  the 
danger  of  bacterial  infection,  must  be 
secured  in  the  sick  room.  The  sputum 
should  be  expectorated  into  a  special 
receptacle  and  this  should  be  burned. 
Drying  should  be  prevented  by  avoid- 
ance of  long  standing.  Droplet  infection 
may  be  avoided  by  placing  a  piece  of 
cloth  in  front  of  the  mouth  during 
coughing  or  sneezing,  and  the  cloth 
should  be  burned.  Patients  with  pneu- 

41 


HARVARD  HEALTH  TALKS 

monia  should  be  isolated  to  guard  others 
against  contact,  droplet  and  dust  infec- 
tion. Those  in  attendance  should  wash 
the  hands  before  eating  in  order  not  to 
carry  infectious  material  to  the  mouth. 
The  soiling  of  bedding  or  clothing  should 
be  avoided.  Soiled  material  should  be 
removed,  handled  without  shaking,  and 
sterilized.  Dry  sweeping  or  dusting  of 
the  sick  room  should  not  be  permitted. 
Eating  utensils  should  be  kept  separate 
and  sterilized.  The  room  vacated  by  a 
patient  with  pneumonia  should  be  thor- 
oughly cleaned  and  disinfected.  Sunlight 
limits  the  danger  of  the  persistence  of 
living  pneumococci  in  the  room. 

These  suggestions  apply  to  the  care  of 
the  sick  room.  Attention  must  also  be 
paid  to  measures  to  limit  the  spread  of 
infectious  material  by  the  public  at 
large.  The  regulations  of  the  Board  of 
Health  forbidding  expectoration  in  pub- 
lic places  should  be  more  strictly  en- 
forced. Contamination  by  turning  the 

42 


PNEUMONIA 

leaves  of  books  and  public  documents 
after  moistening  the  finger  in  the  mouth 
should  be  avoided. 

It  should  be  recognized  that  over- 
crowding greatly  increases  the  danger  of 
transfer  from  person  to  person.  A  factor 
of  great  importance  in  the  army  was  the 
increased  opportunity  for  contagion  in 
the  close  contact  of  susceptible  individ- 
uals in  barracks,  tents,  and  the  mess. 
Such  crowding  is  a  serious  menace  and 
responsible  for  the  loss  of  many  lives. 
Though  unavoidable  in  the  face  of  a 
national  emergency,  the  danger  may  be 
diminished  by  head  to  foot  sleeping, 
screening  by  the  cubicle  system,  and 
separation  by  screens  at  mess.  The 
bedding  and  barracks  should  be  thor- 
oughly cleaned  and  aired.  Overcrowding 
is  to  be  avoided  in  civil  as  well  as  mili- 
tary life  and  an  improvement  of  housing 
conditions  in  our  cities  will  diminish  con- 
tact infection.  As  dust  is  concerned  in 
the  spread  of  respiratory  infections,  the 

45 


HARVARD  HEALTH  TALKS 

amount  of  city  dust  and  smoke  should  be 
diminished.  When  in  any  community 
respiratory  infection  reaches  a  menacing 
prevalence,  mass  meetings  should  be  for- 
bidden, schools  should  be  closed,  and  in- 
fected boats  should  not  land  passengers 
at  uninfected  ports. 

There  are  certain  precautions  which 
apply  particularly  to  the  individual. 
Autogenous  infection  with  organisms 
harbored  in  the  mouth  is  responsible  for 
about  40  per  cent  of  the  lobar  pneu- 
monias and  for  a  large  proportion  of  the 
bronchopneumonias.  Persons  with  an  in- 
fection of  the  upper  parts  of  the  respira- 
tory tract  such  as  accompanies  a  "cold," 
influenza,  tonsillitis,  etc.,  should  avoid 
chilling  of  the  body,  exposure  to  draught 
when  insufficiently  clad,  and  rapid  cool- 
ing when  overheated.  The  danger  of  in- 
halation of  infectious  material  may  be 
diminished  by  breathing  pure  air  free 
from  dust,  the  maintainance  of  an  equa- 
ble temperature  in  the  house,  keeping 

44 


PNEUMONIA 

children  within  doors  on  dusty  days, 
the  wearing  of  a  veil  out-of-doors,  and 
careful  cleaning  of  the  teeth  and  mouth 
during  the  fevers  and  preceding  any 
operative  procedure  under  a  general 
anesthetic.  Operations  under  general 
anesthesia  should  be  avoided  in  other 
than  emergency  cases  during  any  nasal 
infection,  tonsillitis,  or  cough,  and  the 
operation  postponed  until  the  infection 
has  wholly  subsided.  In  the  presence  of 
such  an  infection,  an  imperative  opera- 
tion should  if  possible  be  done  under 
local  rather  than  general  anesthesia,  or 
if  general  anesthesia  must  be  used,  gas- 
oxygen  or  chloroform  is  to  be  preferred 
to  ether. 

Still  another  matter  of  importance  is 
the  recognition  that  there  is  to  a  cer- 
tain degree  a  predisposition  to  pneu- 
monia in  the  lowering  of  resistance  by  an 
inadequate  food  supply,  exposure,  over- 
work and  fatigue,  and  greater  atten- 
tion should  therefore  be  paid  to  enough 

45 


HARVARD  HEALTH  TALKS 

and  proper  food,  sufficient  clothing,  and 
a  suitable  balancing  of  activity  and  rest. 
Preventive  measures  must,  however, 
go  further  than  this  and  strike  more 
nearly  at  the  root  of  the  pneumonia 
problem  and  this  brings  us  to  the  first  of 
the  two  methods  of  attack  with  promise 
for  the  future.  Such  diseases  as  measles, 
whooping  cough,  influenza,  and  diph- 
theria in  which  there  is  an  infection  of 
the  upper  parts  of  the  respiratory  tract 
are  prone  to  be  complicated  or  followed 
by  pneumonia,  usually  of  the  broncho- 
pneumonia  type.  To  eliminate  pneu- 
monia secondary  to  these  diseases,  the 
diseases  themselves  must  be  brought 
under  control.  More  adequate  isolation 
than  is  now  customary  will  diminish  the 
frequency  of  measles,  whooping  cough, 
and  influenza,  but  the  discovery  of  the 
causative  agent  and  a  better  understand- 
ing of  the  mode  of  transmission  are  nec- 
essary preliminaries  to  complete  success. 
It  is  highly  important  that  the  public 

46 


PNEUMONIA 

recognize  our  deficiencies  in  these  mat- 
ters, and  recognizing  them  demand  and 
financially  support  further  investigations 
for  the  solution  of  the  problem.  Regard- 
ing diphtheria  it  may  be  said  that  pres- 
ent knowledge  is  sufficient  entirely  to 
stamp  out  the  disease.  The  brilliant  re- 
searches of  the  past  few  years  have  made 
diphtheria  entirely  preventable.  To 
have  it  will  in  the  future  be  a  reproach  to 
the  intelligence  or  the  enterprise  of  a 
community.  During  1919  about  8,000 
cases  of  diphtheria  were  reported  in  the 
State  of  Massachusetts  with  nearly  600 
deaths.  Not  all  persons  are  susceptible 
to  diphtheria.  A  simple,  safe,  and  relia- 
ble test,  known  as  the  Shick  test,  will 
determine  the  susceptible  individuals 
who  can  then  be  made  immune,  by  the 
injection  of  a  diphtheria  toxin-antitoxin 
mixture.  Our  State  Department  of 
Health  furnishes  to  physicians  the  ma- 
terials for  testing  susceptibility  and  im- 
munization against  the  disease. 

47 


HARVARD  HEALTH  TALKS 

There  is  one  other  hopeful  prospect  of 
success  in  the  prevention  of  pneumonia. 
Typhoid  fever  and  small  pox,  once  the 
scourge  of  armies,  have  practically  dis- 
appeared as  the  result  of  preventive  in- 
oculation and  it  was  natural  to  expect 
that  the  application  of  similar  methods 
might  diminish  the  incidence  of  pneu- 
monia. Successful  immunization  against 
typhoid  fever  is  accomplished  by  the  in- 
jection under  the  skin  of  a  suspension  of 
dead  typhoid  bacilli.  By  the  injection  of 
animals  with  dead  pneumococci  of  any 
type,  a  considerable  degree  of  resistance 
to  virulent  pneumococci  can  be  ob- 
tained. But  for  the  production  of  the 
highest  grade  of  resistance  in  animals  it 
is  necessary  to  inoculate  the  animal  with 
living  cultures. 

Preventive  inoculation  against  pneu- 
monia by  means  of  a  pneumococcus  vac- 
cine was  first  attempted  on  a  large  scale 
by  Wright  among  the  miners  in  South 
Africa.  The  experience  at  the  Premier 

48 


PNEUMONIA 

Mine  in  1913  was  promising.  Among 
seventeen  thousand  inoculated  the  death 
rate  from  pneumonia  was  six  per  thou- 
sand while  among  six  thousand  seven 
hundred  uninoculated  the  death  rate 
was  seventeen  per  thousand.  By  the  use 
of  a  vaccine  containing  types  of  pneu- 
mococci  prevalent  in  the  mines,  Lister 
later  found  that  no  cases  of  pneumonia 
of  the  type  against  which  the  men  had 
been  vaccinated  developed  during  nine 
months  of  observation.  Cecil  and  Austin 
at  Camp  Upton  and  Cecil  and  Vaughan 
at  Camp  Wheeler  obtained  encouraging 
though  inconclusive  results  on  soldiers 
during  the  World  War.  Cecil  and  Blake 
found  that  the  inoculation  of  monkeys 
with  dead  pneumococci  failed  to  protect 
them  against  experimental  pneumonia 
though  it  lessened  the  mortality  from  the 
disease.  For  protection  it  was  necessary 
to  inoculate  monkeys  not  with  dead  but 
with  living  pneumococci.  I  mention  these 
matters  to  acquaint  you  with  the  problem, 

49 


HARVARD  HEALTH  TALKS 

which  is  a  difficult  one  for  the  preven- 
tion of  human  infection  and  must  still  be 
regarded  as  in  the  experimental  stage. 
Thus  far  there  is  not  sufficient  evidence 
to  justify  the  general  adoption  of  pre- 
ventive inoculation  against  pneumonia. 

TREATMENT 

In  discussing  the  treatment  of  pneu- 
monia it  will  be  most  convenient  to  speak 
first  of  general  measures  and  later  of 
specific  therapy. 

General  Measures  of  Treatment. 
Whether  the  patient  should  be  treated  at 
home  or  in  a  hospital  depends  largely  upon 
the  financial  resources  of  the  family.  If 
proper  medical  oversight  and  nursing 
cannot  be  obtained  at  home  it  is  better 
for  the  patient  to  be  moved  to  a  hospital. 
The  decision,  however,  should  be  made 
early  in  the  disease  when  the  patient  can 
stand  the  journey  without  undue  fatigue 
and  the  transfer  should  be  made  in  a 
stretcher  with  the  patient  lying  down. 
BO 


PNEUMONIA 

Every  effort  should  be  made  to  con- 
serve the  strength  and  resistance  of  the 
patient  by  rest,  proper  feeding,  and 
fresh  air.  The  elimination  of  toxic  ma- 
terial may  be  favored  by  an  abundance 
of  water  but  too  large  a  quantity  should 
not  be  given.  The  patient  should  be  ab- 
solutely at  rest  in  bed  and  not  allowed  to 
sit  up,  moved  and  not  allowed  to  move 
himself,  fed  and  not  permitted  to  feed 
himself.  During  the  feeding  he  should 
remain  recumbent,  and  liquid  nourish- 
ment may  be  taken  from  a  glass  through 
a  bent  glass  tube.  There  are  no  special 
indications  regarding  diet  and  the  pa- 
tient may  take  as  much  of  simple  and 
nutritious  food  as  he  can  digest.  During 
the  early  stages  of  the  disease  the  diet 
usually  consists  of  milk  and  milk  prepa- 
rations, broth  and  albumen  water,  with 
a  more  liberal  diet  as  the  fever  subsides 
and  the  appetite  returns.  If  the  bowels 
have  not  moved  a  mild  cathartic  may 
be  given  at  the  outset.  If  abdominal 

51 


HARVARD  HEALTH  TALKS 

distention  from  gas  is  troublesome  or 
if  there  is  vomiting,  all  food  may  be 
stopped  for  a  time.  If  necessary  a  daily 
suds  enema  should  be  given.  The  room 
should  be  well  lighted  and  well  venti- 
lated and  the  windows  thrown  open  to 
secure  an  abundance  of  fresh  air.  Keep- 
ing the  patient  out-of-doors  in  cold 
weather  is  unnecessary,  but  facilities  for 
moving  the  patient  into  a  porch  adjoin- 
ing the  room  are  desirable. 

Patients  with  pneumonia  should  never 
be  left  alone  on  account  of  the  danger  of 
sudden  and  unexpected  delirium  which 
may  lead  to  injury  or  accident. 

Drugs  and  Other  Non-Specific  Meas- 
ures. Are  there  drugs  or  other  measures 
of  value  in  treatment?  Various  special 
methods  of  treatment  have  been  tried  at 
different  times  and  in  different  places. 
Without  going  into  the  matter  in  detail, 
it  may  be  said  that  with  one  exception 
the  infection  is  beyond  our  control  other 
than  by  such  measures  as  tend  to  spare 

52 


PNEUMONIA 

and  support  the  strength  of  the  patient 
by  careful  nursing  and  hygiene  and  the 
alleviation  of  symptoms.  Even  by  these 
simple  means  lives  may  be  saved,  more 
particularly  in  those  cases  in  which  there 
is  a  balancing  between  life  and  death,  and 
the  utmost  care  may  turn  the  scale  in  the 
right  directions.  Special  diets,  drugs  of 
various  kinds,  including  alcohol,  hydro- 
therapy,  venesection,  vaccines,  etc.,  have 
not  been  shown  to  influence  the  course 
and  outcome  of  the  disease.  But  morphia 
is  of  great  value  in  relieving  the  pain  in 
the  side  which  otherwise  prevents  sleep, 
aggravates  the  shortness  of  breath,  and 
harasses  and  fatigues  the  patient.  It  re- 
lieves the  pain,  conserves  the  patient's 
strength,  and  may  enable  him  better  to 
withstand  the  infection.  Digitalis,  a 
drug  with  special  action  on  the  heart, 
may  be  of  value  especially  in  cases  where 
there  is  irregularity  of  the  heart  with 
fibrillation  of  the  auricles.  There  is 
promise  in  the  course  of  time  of  the  de- 

63 


HARVARD  HEALTH  TALKS 

velopment  of  a  specific  drug  therapy.  A 
derivative  of  quinine  known  as  "opto- 
chin,"  discovered  by  Morgenroth,  has 
been  shown  by  experiments  in  animals 
to  protect  against  subsequent  infection 
and  cure  an  otherwise  fatal  infection 
with  pneumococci,  but  large  enough 
doses  to  be  effective  in  man  are  too  dan- 
gerous to  use  and  it  cannot  be  recom- 
mended. Its  discovery,  however,  is  of 
great  importance,  as  it  is  the  firpt  chemi- 
cal agent  definitely  shown  to  have  a  bac- 
tericidal effect  in  the  living  body.  Its 
discovery  is  a  great  incentive  to  further 
investigation. 

Specific  Serum  Treatment  of  Pneu- 
monia. In  discussing  the  recognition  of 
the  different  types  of  pneumococci,  at- 
tention was  called  to  the  specific  pro- 
tective and  curative  action  in  animals  of 
the  serum  of  horses  immunized  against 
the  different  types  of  pneumocoeci.  For 
the  development  of  methods  and  the 
application  of  the  principle  of  serum 

54 


PNEUMONIA 

therapy  to  human  infection,  we  are  in- 
debted to  Dr.  Rufus  Cole  and  his  asso- 
ciates at  the  Hospital  of  the  Rockefeller 
Institute.  It  has  been  shown  that  serum 
produced  by  the  inoculation  of  horses 
with  Type  I  pneumococcus  is  effective  in 
the  treatment  of  pneumonia  due  to  Type 
I  pneumococcus.  Curative  action  of 
Type  II  and  Type  III  horse  serum  has 
not  been  demonstrated.  The  evidence  in 
favor  of  the  use  of  this  serum,  Type  I, 
against  this  particular  type  of  infection 
is  as  follows :  There  is  usually  a  striking 
improvement  in  the  general  condition  of 
the  patients  treated  with  the  serum,  the 
lung  involvement  may  cease  to  extend 
and  the  septicaemia  is  checked.  A  dimi- 
nution of  mortality  is  the  most  signifi- 
cant result.  As  shown  in  the  table, 
Column  E,  the  outlook  in  Type  I  pneu- 
monia untreated  by  serum  is  a  mortality 
of  about  one  third  of  the  cases.  As  shown 
in  column  F,  Cole  has  collected  a  series 
of  495  serum  treated  cases  of  Type 

55 


HAEVARD  HEALTH  TALKS 

I  pneumonia,  including  195  patients 
treated  at  the  Hospital  of  the  Rocke- 
feller Institute,  with  a  total  mortality  of 
10.5  per  cent,  column  H. 

Cecil  and  Blake's  results  of  serum 
treatment  of  experimental  pneumonia  in 
monkeys  are  a  striking  confirmation  of 
the  beneficial  effects  in  man.  Of  five 
monkeys  given  pneumonia  by  intratra- 
cheal  injections  of  otherwise  fatal  doses 
of  pneumococcus  Type  I,  all  recovered 
following  intravenous  treatment  with 
Type  I  antipneumococcic  serum  while 
the  controls  not  so  treated  died.  In  this 
type  of  pneumonia  in  monkeys  the  serum 
exercises  a  specific  therapeutic  effect, 
frees  the  blood  promptly  and  perma- 
nently of  pneumococci,  shortens  the  dis- 
ease and  greatly  modifies  its  severity. 

Serum  treatment  of  other  than  Type  I 
pneumococcus  pneumonia  has  not 
proved  of  value  and  thus  serum  treat- 
ment is  applicable  to  only  one  type  of 
pneumonia,  that  due  to  Type  I  pneumo- 

56 


PNEUMONIA 

coccus  for  which  Type  I  anti-pneumo- 
coccus  serum  is  used.  It  is  important  that 
only  a  reliable  serum  be  employed.  In 
Massachusetts  Type  I  serum  is  made  by 
the  State  Board  of  Health.  In  New  York 
it  is  supplied  by  the  State  and  City 
Boards  of  Health.  The  serum  made  by 
the  State  Board  of  Health  of  Massachu- 
setts is  available  without  charge  for  citi- 
zens of  the  State.  A  question  frequently 
asked  is  whether  or  not  it  is  desirable  to 
treat  all  cases  of  pneumonia  with  Type 
I  serum  irrespective  of  the  type  of  the 
infecting  pneumococci.  This  is  a  natural 
inquiry  inasmuch  as  about  one  third  of 
all  cases  of  lobar  pneumonia  are  due  to 
Type  I  pneumococci.  If  the  question 
could  be  answered  in  the  affirmative  and 
all  cases  irrespective  of  type  treated  with 
Type  I  serum  the  time  necessary  to 
make  a  diagnosis  of  the  type  would  be 
saved  and  considerable  trouble  in  the 
performance  of  the  laboratory  tests 
avoided.  Another  inquiry  is  whether  or 

57 


HARVARD  HEALTH  TALKS 

not  a  single  administration  of  Type  I 
serum  may  not  be  given  to  the  patient  as 
soon  as  the  diagnosis  of  lobar  pneu- 
monia is  made  and  later  injections  only 
after  finding  that  Type  I  pneumococcus 
is  the  cause  of  the  process.  Such  a  pro- 
cedure would  have  the  merit  of  very 
early  administration  and  in  the  serum 
therapy  of  pneumonia  as  in  serum  ther- 
apy for  diphtheria  or  meningitis,  the 
earlier  the  treatment  is  begun  the  more 
successful  is  it  likely  to  be.  But  in  an- 
swer to  both  questions  it  may  be  said 
that  the  occurrence  of  certain  reactions 
in  certain  individuals  after  the  adminis- 
tration of  alien  serum  make  it  desirable 
not  to  give  serum  to  all  patients  and  thus 
subject  about  two-thirds  of  all  cases  of 
pneumonia  unnecessarily  to  these  reac- 
tions, it  being  understood  that  in  other 
than  Type  I  infections  the  serum  is  in- 
effective. Too  much  stress,  however, 
cannot  be  placed  on  the  importance  of 
the  earliest  possible  diagnosis  of  the  type 

58 


PNEUMONIA 

of  organism  giving  rise  to  the  infection  in 
order  that  Type  I  infections  may  be 
treated  with  serum  at  the  earliest  pos- 
sible moment. 

Another  question  of  interest  is  whether 
all  cases  of  pneumonia  due  to  Type  I 
pneumococcus  should  be  treated  with 
the  serum.  In  young  children  the  diffi- 
culties of  getting  the  serum  into  the 
veins  are  such  as  to  make  its  administra- 
tion undesirable. 

Precautions  in  the  Use  of  Alien  Serum 
in  Man.  Certain  precautions  should  al- 
ways be  used  in  the  administration  to 
man  of  serum  obtained  from  an  alien 
species  such  as  the  horse,  and  this  ap- 
plies not  only  to  the  treatment  of  Type  I 
pneumonia  with  Type  I  antipneumococ- 
cus  serum  but  also  among  others  to  the 
treatment  of  meningitis  with  antimen- 
ingococcus  serum,  the  prevention  and 
treatment  of  diphtheria  with  diphtheria 
antitoxic  serum,  and  the  prevention  and 
treatment  of  tetanus  with  antitetanus 


HARVARD  HEALTH  TALKS 

serum.  All  these  sera  are  made  by  the 
immunization  of  horses  and  when  the 
resistance  of  the  horse  is  raised  to  a  suffi- 
cient degree  the  horse  is  bled.  The  blood 
is  allowed  to  clot  and  the  separated 
serum  removed  and  bottled  ready  for 
use.  The  treatment  of  pneumonia  is  by 
the  injection  of  a  large  amount  of  the 
immune  serum  directly  into  the  veins  of 
the  patient.  The  serum  used  in  the  pre- 
vention and  treatment  of  diphtheria  is 
usually  injected  under  the  skin  but  at 
times  is  also  given  directly  into  the  veins. 
Antimeningococcus  serum  is  usually 
given  directly  into  the  spinal  canal,  at 
times  also  into  the  veins.  Antitetanus 
serum  is  injected  under  the  skin  to  pre- 
vent the  disease  and  both  into  the  spinal 
canal  and  into  the  veins  in  treatment. 

Following  the  administration  of  horse 
serum  by  any  of  these  routes,  certain 
symptoms  of  a  varying  degree  of  sever- 
ity may  arise  in  susceptible  individuals. 
The  symptoms  are  likely  to  be  more 


PNEUMONIA 

severe  when  large  amounts  of  serum  are 
injected  directly  into  the  veins  and 
hence  special  caution  must  be  exercised 
in  this  treatment  of  pneumonia.  These 
symptoms  have  nothing  to  do  with  the 
preventive  and  curative  action  of  the 
serum  but  arise  in  consequence  of  the 
entrance  directly  into  the  body  of  serum, 
containing  substances  of  a  protein  na- 
ture common  to  the  horse  but  foreign  to 
human  beings.  Fortunately  only  a  small 
proportion  of  patients  are  sensitive  to 
horse  serum  and  the  susceptibles  are 
easily  recognized  by  certain  simple  pro- 
cedures. In  the  first  place  the  patient 
under  consideration  for  serum  treatment 
should  always  be  asked  whether  or  not 
he  is  subject  to  or  has  had  hay  fever  or 
asthma,  or  if  he  has  ever  previously  been 
given  an  injection  of  horse  serum  and  an 
affirmative  answer  places  him  in  the 
group  of  patients  likely  to  be  sensitive  to 
serum,  and  indicates  that  special  cau- 
tion should  be  observed  in  the  use  of 

61 


HARVARD  HEALTH  TALKS 

horse  serum.  In  all  candidates  for  serum 
treatment,  however,  irrespective  of  the 
response  to  these  questions  sensitiveness 
to  horse  serum  should  be  tested  directly 
by  what  is  known  as  an  intradermal  skin 
test  performed  by  the  injection  into  and 
not  under  the  sterilized  skin,  by  means 
of  a  very  fine  needle,  of  a  small  amount 
(0.02  c.c.)  of  sterile  horse  serum  diluted 
(1 :10)  with  normal  salt  solution.  To  pre- 
vent confusion  with  a  local  reaction  due 
to  the  injection  itself  an  equal  amount  of 
normal  salt  solution  alone  is  similarly 
injected  into  another  part  of  the  skin 
and  the  two  sites  of  injection  are  ob- 
served. In  individuals  sensitive  to  horse 
serum  there  develops  at  the  site  of  the 
injection  of  the  horse  serum,  usually 
within  about  five  minutes  a  peculiar 
white  elevation  resembling  nettle  rash 
and  spoken  of  as  an  urticarial  wheal  and 
surrounded  by  a  zone  of  redness.  The 
urticarial  wheal  slowly  increases  in  size, 
may  reach  that  of  a  half  dollar  within  an 


PNEUMONIA 

hour  and  then  slowly  subsides  while  the 
site  of  the  injection  of  salt  solution  pre- 
sents no  such  appearance.  If  the  injec- 
tion of  horse  serum  is  negative  there  is 
almost  but  not  quite  absolute  assurance 
that  the  patient  is  insensitive  to  horse 
serum.  As  an  added  precaution  there- 
fore every  patient  to  be  subjected  to 
serum  treatment  is  first  protected  by  a 
procedure  which  will  increase  his  toler- 
ance to  the  alien  serum.  This  procedure 
is  spoken  of  as  desensitization  and  con- 
sists in  the  administration  under  the 
skin  of  0.5  to  1.0  c.c.  of  horse  serum,  the 
absorption  of  which,  as  has  been  shown 
by  animal  experiment,  enables  even 
highly  sensitive  animals  to  tolerate  large 
amounts  of  serum  without  trouble.  In 
patients  without  a  history  of  hay  fever, 
asthma,  or  the  previous  injection  of 
horse  serum,  and  with  negative  skin 
tests,  the  intravenous  administration  of 
serum  may  be  given  within  a  few  hours 
after  desensitization. 


HARVARD  HEALTH  TALKS 

Administration  of  Serum.  The  serum 
is  usually  given  into  a  vein  at  the  bend  of 
the  elbow.  The  serum  should  be  warm 
and  the  first  part  of  the  first  injection 
should  be  given  slowly,  fifteen  minutes 
being  occupied  in  giving  the  first  fifteen 
cubic  centimeters.  The  slow  adminis- 
tration of  the  first  fifteen  cubic  centi- 
meters of  serum  is  desirable  as  an  added 
safeguard  against  sensitiveness  to  serum, 
the  symptoms  of  which  are  likely  to 
occur  at  once  if  they  are  to  develop  at 
all.  With  the  completion  of  the  slow 
injection  of  the  first  fifteen  cubic  centi- 
meters, the  serum  may  be  allowed  to 
enter  the  vein  more  rapidly,  about  a  half 
hour  usually  being  consumed  in  giving 
the  first  dose  of  100  cubic  centimeters. 
Subsequent  doses  are  given  usually  at 
eight  hour  intervals  while  the  tempera- 
ture is  102  or  above. 

Stress  has  been  laid  on  the  precautions 
which  should  surround  the  administra- 
tion of  horse  serum  and  if  these  precau- 
64 


PNEUMONIA 

tions  are  observed  no  unfavorable  symp- 
toms should  occur  in  consequence  of  the 
injections.  The  method  to  be  used  in  the 
administration  of  serum  to  sensitive  in- 
dividuals cannot  be  described  here.  For 
this  and  further  details  in  the  use  of  the 
method,  Cole's  article  on  Acute  Lobar 
Pneumonia  in  Nelson's  Loose-Leaf  Med- 
icine may  be  consulted,  but  before  leav- 
ing the  subject  mention  should  be  made 
of  three  types  of  reactions  which  may 
follow  the  intravenous  use  of  horse 
serum. 

Reactions  following  Serum  Injections. 
During  or  immediately  following  the  in- 
jection of  serum  in  sensitive  individuals 
there  may  develop  what  is  spoken  of  as 
an  anaphy lactic  reaction.  The  precau- 
tions already  described  are  designed  to 
avoid  such  reactions.  When  serum  is 
given  to  sensitive  individuals  a  general 
urticarial  eruption  or  an  asthmatic  at- 
tack with  rapidity  and  weakness  of  the 
pulse  may  occur.  Such  an  attack  may  be 

65 


HARVARD  HEALTH  TALKS 

fatal.  Atropine  sulphate  1/120  grain  and 
adrenaline  chloride,  10  minims  of  a 
1:1000  solution  subcutaneously  will  usu- 
ally relieve  the  symptoms. 

A  second  type  of  reaction  which  may 
occur  in  consequence  of  serum  adminis- 
tration is  a  rapid  rise  of  temperature 
which  usually  occurs  within  an  hour,  ac- 
companied by  chill  or  chilliness,  some 
shortness  of  breath  and  cyanosis  and 
some  elevation  of  pulse.  This  is  called 
a  thermal  reaction.  The  temperature 
elevation  is  of  short  duration  and  is 
followed  by  a  fall  frequently  to  below  the 
previous  temperature  level.  This  reac- 
tion is  rather  disturbing  to  the  patient 
but  is  not  dangerous. 

A  third  consequence  of  serum  treat- 
ment, more  remote  in  point  of  time,  is 
what  is  known  as  serum  disease,  which 
occurs  in  about  50  per  cent  of  the  pa- 
tients, about  one  week  or  later  after  the 
last  injection  of  serum  and  lasts  for  a 
number  of  days,  or  a  week  or  more.  The 


PNEU&CfNlA 


symptoms  are  elevated  temperature, 
urticarial  skin  rashes,  swelling  of  the 
skin,  stiff  and  painful  joints,  and  en- 
larged glands  and  spleen.  This  condi- 
tion though  troublesome  is  not  serious. 
A  soothing  skin  wash  and  adrenaline 
chloride  solution  subcutaneously  will 
give  some  relief  from  the  troublesome 
itching. 

CONCLUSIONS 

In  conclusion  let  me  say  that  though 
pneumonia  still  heads  the  list  of  acute 
diseases  most  widespread  and  fatal  to 
mankind  and  though  the  problem  is  not 
yet  completely  solved,  yet  much  valu- 
able knowledge  has  already  been  gained 
and  there  is  a  hopeful  prospect  of  at 
least  partial  success  in  prevention  and 
treatment. 

Within  the  past  ten  years  important 

advances  have  been  made  in  the  study 

of  the  pneumococcus.     Its  distribution 

and  mode  of  transmission  are  better  un- 

e? 


HEALTH  TALKS 

derstood.  The  pneumococcus  has  long 
been  known  to  be  a  common  inhabitant 
of  the  normal  mouth,  as  well  as  the 
cause  of  pneumonia,  but  it  has  only  re- 
cently become  apparent  that  all  pneu- 
mococci  are  not  alike  in  their  disease 
producing  power.  The  kinds  most  com- 
monly the  cause  of  the  more  severe  types 
of  pneumonia,  Types  I  and  II,  are  al- 
most wholly  confined  to  patients  with 
pneumonia  and  to  persons  intimately 
exposed  to  them.  This  discovery,  to- 
gether with  the  knowledge  that  in  gen- 
eral the  passage  of  bacteria  through 
animals  increases  their  virulence,  makes 
it  desirable  to  regard  pneumonia  as  a 
contagious  disease  and  guard  against 
transfer  of  the  infectious  agent  from  the 
sick  to  the  well  with  much  greater  care 
than  was  formerly  the  custom.  The 
methods  of  preventing  such  transfer  are 
already  well  understood  and  should  be 
much  more  strictly  applied.  Conditions 
of  overcrowding  are  now  known  to  be 

68 


PNEUMONIA 

important  in  increasing  the  prevalence 
of  the  disease  and  should  whenever  pos- 
sible be  avoided. 

A  most  significant  advance,  capable  of 
saving  many  lives,  has  already  been 
made  in  the  treatment  of  pneumonia  due 
to  Type  I  pneumococcus  with  Type  I 
antipneumococcus  serum.  The  earliest 
possible  administration  of  the  serum  is 
essential  for  the  best  results  and  it  is 
therefore  imperative  to  make  a  prompt 
diagnosis  of  the  type  of  infection. 


PRINTED  AT 

THE  HARVARD  UNIVERSITY  PRESS 
CAMBRIDGE,  MASS.,  U.  8.  A. 


THIS  BOOK  IS  DUE  ON  THE  LAST  DATE 
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DAY  AND  TO  $1.OO  ON  THE  SEVENTH  DAY 
OVERDUE. 


DEC    7   1933 

DEC     8  1933 

°£C           ?935 

MAY  23  1d43 

SEP  28  t&3 

3! 

£PR  12  1954 

n  nD    r-          1QRA 

APR  5      ISO* 

OcK'57RG 

462868 


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